脊髓型颈椎病手术前后MRI的研究

目的：评价脊髓型颈椎病手术前后MRI表现及临床意义。方法：46例患者颈前路手术前后均行MRI的检查,按脊髓的受压程度及脊髓内信号改变分类,观察比较术前和术后MRI的变化与临床表现的关系。结果：脊髓受压程度与临床症状的严重程度密切相关,受压程度越重,临床表现越重（P＞0．05）,术后脊髓形态无恢复、髓内高信号未消失者术后恢复差。高信号消失或明显降低者术前症状轻,手术效果较好。结论：MRI对脊髓型颈椎病预后判断有重要意义。     

颈椎间盘突出非手术治疗髓核自发性重吸收1例并文献综述

<正>脊髓型颈椎病是造成老年人脊髓功能障碍最常见的原因之一[1],颈椎退变常导致脊髓功能障碍以及脊髓血管的压迫。在北美,脊柱退行性疾病占非创伤性脊髓损伤的54%,55岁以上人群中约50%的人被影像学诊断为颈椎病,约10%的人临床诊断为脊髓型颈椎病[2]。脊髓型颈椎病通常表现为颈、肩部疼痛,上肢麻木或感觉异常,下肢无力,步态困难。脊髓型颈椎病发病隐匿,脊髓病变水平以下的上运动神经元的损害占主导,早期主要以颈部僵硬为主要表现,随后出现颈肩部以及上肢疼痛,当颈椎病患者发展到脊髓压迫或功能障碍的症状和体     

前路颈椎间盘切除并植骨融合治疗脊髓型颈椎病

颈椎病是一种中年以后的多发病，其症状表现多种多样。可分为神经根型、脊髓型、椎动脉型、交感神经型和混合型。脊髓型颈椎病主要表现为以四肢瘫痪为主。原因是颈椎间盘脱出形成骨嵴引起的脊髓压迫症状，X线片上病变椎间盘狭窄，椎体增生，特别是后缘增生，CT片上示占位在椎体后椎管前壁，脊髓压迫症状常较严重，MRI片可见退变的椎间盘压迫脊髓。在治疗上采用保守和手术治疗方法。自2000年3月-2003年8月我院8例脊髓型颈椎病患者经保守治疗无效后，采用前路手术切除椎间盘并植骨融合治疗，随访2年，取得很好的疗效，现总结资料报告如下。     

脊髓型颈椎病MRI影像学形态改变与临床评价的相关性

目的探讨脊髓型颈椎病脊髓MRI影像学形态改变与临床评价的相关性。方法收集无颈脊髓压迫102例(对照组)及脊髓型颈椎病41例(患者组)资料,测量对照组颈椎MRI T_2脊髓轴位像上C_(2～3)、C_(3～4)、C_(4～5)、C_(5～6)、C_(6～7)脊髓横断面横径、矢状径、面积和患者组颈椎MRI T_2脊髓轴位像上C_(2～3)及主要受压节段的脊髓横断面横径、矢状径、面积。结果患者组JOA评分与脊髓横断面横径、矢状径、(横径+矢状径)改变率无明显相关性(P 0. 05),JOA评分与横断面积改变率有显著相关性(P 0. 05)。结论脊髓型颈椎病MRI脊髓横径、矢状径改变率与临床症状无明显相关性,而脊髓横断面积改变率与临床症状有显著相关性。不能单纯从脊髓横径、矢状径改变来评估临床症状严重性。     

脊髓型颈椎病前后路减压的比较

目的：比较脊髓型颈椎病前路和后路外科手术的疗效。分析影响疗效的预后因素。方法：对106例前后路减压后脊髓型颈椎病患者通过信函，电话采访和复诊等方式进行了随访，平均随访时间为38个月（5－84个月），平均术前症状时间为26个月（5－79个月），年龄分组为大于55岁组和小于55岁组；按照JOA评分系统评价术前和术后神经功能状态。结果：术前症状时间与恢复率有显著相关性（R＝0．544），术后1个月76例前路手术患者，61例有改善；30例后路手术患者27例有改善，最后1次随访前路57例改善，后路21例有改善，年龄组间的症状时间，下肢症状时间和术后JOA评分有显著差异，结论：前，后路手术在早期均有较好的疗效，其疗效在晚期呈进行性下降，脊髓型颈椎病需要手术治疗。     

重视脊髓型颈椎病的诊断与严格手术指征

随着先进诊疗技术的应用，对脊髓型颈椎病发病机制的认识和诊断水平有了较大程度的提高，其外科治疗也已在全国各地陆续开展。但近来我们屡屡发现临床中脊髓型颈椎病误诊、误治的现象，故再提重视其诊断及严格手术指征，并同广大临床医师商榷，旨在提高我国对脊髓型颈椎病的诊疗水平，减少失误。一、脊髓型颈椎病的基本概念和诊断标准脊髓型颈椎病是颈椎退行性疾病的一种，是以椎间盘退行性变为基本病理基础，相邻椎体节段的椎体后缘骨赘形成，以此构成对脊髓和（或）支配脊髓血管的压迫因素，导致不同程度的脊髓功能障碍的疾病。本病将越来…     

后伸位MRI对脊髓型颈椎病早期诊断与治疗的价值

[目的]证实后伸位颈椎MRI对脊髓型颈椎病早期诊断的价值及初步探讨对动态受压的脊髓型颈椎病患者行综合保守治疗的效果.[方法]统计有脊髓型颈椎病的早期临床症状,但经常规的中立位颈椎MRI检查,没有颈脊髓受压表现的患者31例,在常规颈椎中立位MRI的基础上,加行颈椎后伸位MRI检查,测量颈脊髓与硬膜囊矢状径比值,并根据结果进行分组,如后伸位MRI上有颈脊髓受压表现,就将这类患者随机分为A、B两组,若无受压则为C组,对A组行综合保守治疗,B、C组不予任何治疗,随诊观察2年,比较各组JOA评分的变化.[结果] 31例患者中有25例在后伸位MRI上出现了颈脊髓受压的表现;A组有13例患者,两年后JOA评分较入组时明显上升,且有显著性差异(P＜0.05).B组有12例患者,2年后JOA评分下降,较入组时也有显著性差异(P＜0.05).C组为6例,两年后JOA评分无明显波动,也无显著性差异.[结论]后伸位颈椎MRI是常规中立位颈椎MRI的一个重要补充,它可以早期诊断脊髓型颈椎病;对于动态受压的脊髓型颈椎病患者,早期的的综合保守治疗有效.     

对颈椎病外科治疗决策应考虑的问题

对颈椎病的外科治疗要综合考虑才可制定好治疗决策，笔者认为有9个方面的问题需要考虑： （1）首先要考虑有无手术指征？对于脊髓型颈椎病要选择积极尽早手术；神经根型如症状重、反复发作、影响生活和工作、经正规保守治疗3个月疗效不好的才考虑手术；对明确诊断的椎动脉型、交感型如症状重、反复发作、经保守治疗无效的也应手术。（2）选择前路还是后路？对下颈椎脊髓型颈椎病前后路选择多年以来一直存在争议，一般认为1、2个节段以脊髓前方压迫为主的宜行前路减压：多节段压迫尤其合并发育性椎管狭窄的宜行后路减压（上下减压范围须超出病变部位的一或二个节段）。颈脊髓前后均存在明显压迫的患者行一期前后路减压还是两次手术减压学术上也存在不同观点，笔者认为如全身健康状况不好、年龄较大、有较严重的伴随疾病等情况时应分期手术，且不可为了赶时髦而不考虑安全。事实上，脊髓前后同时存在多节段较严重压迫时，多数患者仅仅需要一次后路椎板成形减压术。     

颈前路显微外科手术治疗脊髓型颈椎病41例

目的 探讨颈前路显微外科手术治疗脊髓型颈椎病的临床疗效.方法 2007年10月至2010年8月采用颈前路显微外科手术治疗脊髓型颈椎病41例,摘除压迫在脊髓及神经根的髓核和软骨终板,使脊髓彻底解放压迫,钛椎间融合器加前路钛钢板固定.结果 41例中,术后38例获1.0～2.5年随访,疗效按照日本矫形外科协会评定法评定,结果优13例,良21例,中3例,差1例,优良率为89.47%.结论 颈前路显微外科手术治疗脊髓型颈椎病临床疗效良好.     

颈前路显微外科手术治疗脊髓型颈椎病41例

目的 探讨颈前路显微外科手术治疗脊髓型颈椎病的临床疗效.方法 2007年10月至2010年8月采用颈前路显微外科手术治疗脊髓型颈椎病41例,摘除压迫在脊髓及神经根的髓核和软骨终板,使脊髓彻底解放压迫,钛椎间融合器加前路钛钢板固定.结果 41例中,术后38例获1.0～2.5年随访,疗效按照日本矫形外科协会评定法评定,结果优13例,良21例,中3例,差1例,优良率为89.47%.结论 颈前路显微外科手术治疗脊髓型颈椎病临床疗效良好.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.